It is rare that a week passes without a prominent newspaper column, magazine article, or TV program extolling the virtues (and sometimes the downside) of cosmetic surgery. The search for longevity and youth pervades our society. We all protest the reminder of the passage of time that we see in the mirror each morning. Most of us age 40 or above have stretched our face and neck skin back with our hands to note what it would look like after a facelift. The following will introduce the reader to the fundamental operation available for rejuvenation of the neck and face commonly known as the facelift or rhytidectomy (face and neck lift).
Basic Anatomy
The facial skeleton determines the basic shape of the face. The shape of your nose, the prominence of your chin and cheekbones, and the height and width of your face are determined by the anatomy of the facial bones. Aside from changes in the teeth, very few of the changes we see in the aging face are due to skeletal changes. The soft tissues overlying this bony framework exist basically in three layers, each of which contributes to aging changes in the face.
The deepest layer consists of the muscles of facial expression. These muscles are arranged around the forehead, eyes, ears, nose, mouth, and neck. All of the movements of the face are due to contraction of these muscles. Stretching and losing tone in these muscles results in sagging of the face. The most important of these is the platysma muscle, which is a thin sheet‑like muscle that extends from the lower neck up to the lower face. In youth, these muscles are tight and give the throat and neck a clean and sculpted look. With the passage of time this muscle loosens and the area under the chin becomes loose and folds appear. These folds are sometimes referred to as the "turkey gobbler" effect. The prominent bands that often exist on each side in the upper front of the neck are actually the front edges of the platysma muscle.
The outermost layer is the skin. As we age the facial skin becomes looser and more wrinkled. This process is promoted by excessive sun exposure and smoking. Your choice of parents is also important because youthful skin definitely is inherited. With time, the elasticity of the skin decreases and becomes looser, just like the elastic in old socks stretches out and actually seems bigger than when the elastic was new and tight. As the skin becomes looser, creases and wrinkles form at the areas of greatest mobility. The areas of the face with the most movement (the eyes, mouth and forehead) show the greatest changes.
The fatty middle layer, lies between the muscular layer below, and the skin above. In youth, the fat was evenly distributed throughout the face. With the passage of time, the fat responds to gravity and is pulled downwards, accumulating in the jowl area and the area under the chin. The fat usually decreases in the cheek area giving a hollow look to the cheeks.
General Facts
There is no "best time" for a facelift. In certain individuals with premature aging changes, a facelift may be indicated at age 35. Most patients are in the age 40 to 65 group. However, assuming good health, there is no upward age limit. Although a greater percentage of facelift patients are women, men have become more and more comfort¬able with facial aesthetic surgery and are undergoing this procedure. Regardless of gender, the ideal facelift candidate is a healthy patient of normal body weight, with skin laxity of the jowl area and neck. This procedure will help to recap¬ture a more youthful appearance. Expectations must be realistic. Facial cosmetic surgery will not make you young, will not necessarily improve your personal relationships, or will not improve your position at work.
Patients who use tobacco products, drink excessive alcoholic beverages, or have had excessive sun exposure in their lifetime have higher rates of complications and may not achieve optimum results.
Pre-Operative Considerations
Before discussing any surgical procedures with you, Dr. McMenamin will review your general health history and current skin care regimen. For patients who have a chronic health problem, we can often work with your doctor to prepare you to safely undergo a cosmetic procedure.
Dr. McMenamin will discuss your particular facial characteristics and your goals for improvement in detail. Facial photographs are an important part of that aesthetic facial analysis. Computer imaging is also helpful to demonstrate to the patient an approximation of the types of changes to be expected. Asymmetries and problem areas will be pointed out to you that you may have been previously unaware of. To meet your described goals, other procedures may be discussed including brow lift, eyelid tuck (blepharoplasty), chin augmen¬tation (mentoplasty), nasal surgery (rhinoplasty), laser/chemical resurfacing, dermabrasion, glycolic acid and Retin A treatment.
The Pre-Operative Visit
Approximately two weeks before surgery, you will attend your “pre op.” During this visit, the doctor or the physician assistant will review your past medical history and perform an appropriate physical exam. You will also be given general information about what to expect the day of surgery and how to take care of yourself post-operatively. Surgical patients are required to discontinue all aspirin products and anti-inflammatories, Vitamin E and C, alcoholic drinks, and tobacco products for two weeks before and after the surgical procedure. Recently, Ginko Biloba, St. John’s Wort, and garlic were added to this list because all of these things can increase your risk for bleeding during and/or after the procedure.
All surgical patients are required to have laboratory work (blood and/or urine tests) seven to ten days prior to surgery. Also, depending on your age and health history, you may be required to have an EKG (heart tracing) and/or a chest x-ray. Your personal health insurance will often cover the cost of these tests. It is not included in the surgery fee.
Prior to seeing the surgeon, you will be asked to read the operative consent form that outlines the risks and benefits of the proposed surgery. Dr. McMenamin will review the consent form with you in detail and answer any remaining questions you have.
Antibiotics, a disinfectant soap, and possibly a mild blood pressure medication may be prescribed for the morning of surgery to ingest/use before you arrive.
The Night Before Surgery
It is beneficial to get a good night’s sleep on the night before surgery. Try to spend a quiet night at home. If you must have a pre op "night out," plan this for earlier in the week. We may ask you to shower and wash into your hair with the disinfectant soap that was provided to you. It is important to remember to EAT OR DRINK NOTHING AFTER MIDNIGHT, including water, for 8 hours prior to surgery.
The Operation
You will be given a time to report to our facility for your surgery. It is very important to be on time. After changing into a hospital type gown, you will be taken to the operating room and seated in the surgical chair in a semi-reclining position. An intravenous line will be inserted, application of vital sign monitors will be achieved, and sedative medications administered until you are quite comfortable. Your face, hair and neck will be gently washed with a disinfectant solution, and sterile drapes applied. You will not be allowed to touch your facial area once it is prepared for surgery. If you become aware of an itch, ask the surgeon or the assistant to scratch it for you.
Dr. McMenamin will draw the incision lines on your face and chin with a marking pen. He or the physician assistant will numb the area with local anesthetic solution. This process is a little uncomfortable, but you will be well sedated and the process goes quickly. The local anesthetic allows you to be pain free throughout the remainder of the procedure. If at any time you are having discomfort or anxiety during the procedure, tell the surgeon or his assistant so that more medication can be used to alleviate that.
The incision is created with a scalpel blade. It starts in the hair of the sideburn, and continues down just in front of the ear to where the earlobe is attached to the face. Then, the incision turns underneath the earlobe to extend onto the back of the ear, across skin behind the ear, and into the hairline. (Dr. McMenamin will have demonstrated for you where the incisions will be during your pre op.) A scar along this incision line is unavoidable, but most of it will be hidden by the hair and behind the ear. An additional incision is made under the chin to sculpt the neck area. The areas that are not hidden are the just in front of the ear, between the back of the ear and hairline and under the chin. However, these areas usually heal with an acceptable but visible scar.
The neck skin is undermined first from the incision under the chin. Excess fat may be suctioned from the neck and jowl areas and excess tissue will be sculpted. The facial area, one side at a time, is addressed next. Elevation of the skin from the deeper tissues is accomplished, usually extending to the mid cheek area. The facial and platysmal muscle layer (SMAS) is identified. It is undermined and then trimmed of any excess. It is then tight¬ened with sutures to provide better support for the jowl and neck. The undermined skin is then passively lifted up and back. The excess skin is trimmed and removed, and the edges are carefully reposi¬tioned and sutured into place.
Upon completion of the procedure, a thick, gauze dressing will be applied. This applies gentle pressure to the surgical area to reduce the risk of bleeding. It is normal to have a small amount of blood or secretions during the first night. The dressing will help absorb that. You will remain in the operating room or the recovery area until you are sufficiently alert and ready to go home. Upon discharge, pain medication will be provided. Also, verbal and written instructions will be reviewed for your home care with you and your caretaker. A responsible, adult friend or relative must drive you home and attend to you the first 24 hours after surgery. Under NO circumstances will you be allowed to drive yourself home.
The Evening of Surgery
You may feel drowsy for several hours following surgery until the sedatives completely wear off. Also, pain medication can make you drowsy. You will have noticeable swelling especially in the cheek and eye area because those areas are not compressed. This swelling may make wrinkles around the mouth and eyes less apparent. Unfortunately, most of those wrinkles will return as the swelling subsides. You may notice some bruising at the base of the neck.
Keeping your upper body elevated in the days after surgery will minimize swelling and promote faster resolution of any residual swelling (Figure 2). You must stay in a near sitting position for 24 hours a day for the first 10 days to reduce swelling, bruising, and to minimize discomfort. A recliner chair, a cushioned outdoor lounge chair, or a sofa with several pillows to prop you up will work nicely.
Ice applied to the surgical site(s) will also decrease swelling. You should apply ice packs to the face/neck areas 20 minutes out of every hour for the first 72 hours (3 days), then 12 hours out of the day for and additional 3 days. Continue as needed if swelling or discomfort persists. In general, the discomfort following a facelift is mild and usually felt most along the sides of the face and neck. Tylenol should be taken as directed on the bottle in the first 24 hours. The pain medication supplied to you should only be taken as needed after the first 24 hours. The pain medication, usually Darvocet, should be taken on a full stomach to avoid severe nausea and vomiting. Most patients have very little pain and Tylenol can suffice. Any occurrence of sudden, severe, and persistent pain or swelling is an indication of a problem and should be immediately reported to your surgeon. This may mean that a hematoma (blood collection under the skin) has occurred and will require immediate attention. It is not unusual to have minor bleeding after a facelift. This will often show through on the bandage but should not soak the dressing. If you have a questionable amount of bleeding, call Dr. McMenamin.
Do not drink alco¬hol, smoke, take aspirin or anti-inflammatory compounds, or Vitamins E or C in the two weeks following surgery. Excessive bleeding under the skin may occur. Straining on the toilet due to constipation or forceful vomiting can increase the blood pressure in the blood vessels to the head and cause marked post operative bleeding. A rapidly acting laxative (i.e. Milk of Magnesia) or anti nausea medication will be recommended.
It is normal to feel apprehensive about what you are experiencing after surgery. Even those patients who are veterans to surgery experience some level of anxiety. Remember that we are here to answer your questions to relieve your anxieties. Don’t hesitate to call us if you need reassurance.
The First Post-Operative Visit
You will be given an appointment for the day after your surgery. Your gauze dressing will be removed, the surgical areas will be examined, and then a new dressing will be applied. Any questions you have will be answered. Be aware that swelling, bruising, skin discoloration, and notice¬able sutured incisions will be visible. Do not be alarmed. This is normal for this stage and will rapidly improve.
The First Post-Operative Weeks
The gauze dressing must be worn for approximately 5 days. The pressure it applies will greatly decrease your risk for complications. Swelling and bruising usually reach their peak at approximately 5 days. Each day after that, you should note a gradual improvement. Bruising is the result of blood infiltrating the soft tissue as the result of trauma. It routinely is most visible along the jaw line and the base of the neck. It will go through a number of color changes from purple to yellow or green before finally disappearing, usually by the end of the second or third week.
After the gauze dressing is removed, you will be provided an elastic compression facial garment. It must be worn for 24 hours a day for the first 2 weeks, then as much as possible the second 2 weeks. After that, you will wear it only at night. You will be instructed on wound care using hydrogen peroxide and/or Bacitracin Ointment on the incision lines twice a day.
Remember that during surgery, the skin of your face and neck is lifted completely away from the deeper tissue. It is extremely important that your skin reattach smoothly and snuggly. You can facilitate the best possible result by keeping the face quiet and the dressings in place as directed.
Suture removal will begin around post operative day 5 – 7. The first sutures to be removed are immediately in front of the ear and under the chin. The remaining sutures will be removed about 2 - 3 days later. You may CAREFULLY wash your hair 24 to 36 hours after ALL the sutures are out. Do not use a hot hairdryer, curling iron, or hot rollers until the feeling is back in your skin sufficiently to avoid burning yourself.
You may begin resuming your normal activities, excluding exercise, approximately 2 weeks after surgery. This amount of time is necessary to allow sufficient healing for your face to appear “normal” cosmetically, and also to allow you to recover your strength. Occasionally, patients require a longer period of time. Initial concern about what your family, friends, and co-workers will think or notice is normal. You may wonder, "Can they tell that I've had a facelift?” or "Can they see my swelling, incisions, and bruising?" We have found that most comments, if any, tend to relate to how well you look, how rested you look, or “Have you lost weight?” It is unlikely that they will know the real reason you look so good unless you tell them! They won’t hear about it from us. Our office maintains strict confidentiality about any care that we deliver to our patients.
Commonly asked Questions
How long will my facelift last?
Patients often ask how long a facelift will last. Only general guidelines can be given because each patient is different in terms of skin thickness, laxity, sun damage, muscle tone, amount of fat, and rate of aging. The aging process continues with or without a facelift. We may be able to turn back the clock, but it still continues to march forward. However, if you appear to be 8 10 years younger after surgery, this difference should persist the rest of your life. For example, if after surgery, you appear to be about 50 instead of 58 years old, then at age 68 you should expect to appear to be about 60. In time, you may need a second procedure to maintain the best appearance.
What is the best age to have a facelift?
The average age for the first time facelift patient is 45 - 65 years. However, patients are undergoing facelifts at younger ages. Many experts believe that the younger the patient at the initial time of surgery, the better the long-term results. On the other hand, assuming good health, even patients in their 70's and 80's are candidates for facial rejuvenation procedures.
Will there be scars?
Patients sometimes assume that "plastic surgery" is done without any scarring whatsoever. Any incision (cut in the skin) will leave a permanent scar. In cosmetic surgery, proper placement of incisions and special suturing techniques, should keep residual scars as inconspicuous as possible. Very rarely, there can be excessive scarring (hypertrophic scarring) that needs additional treatment.
Is there a chance that I will need to have the facelift redone?
25% to 30% of facelift patients do have secondary procedures done about 5 to 10 years later. These may range from a second complete facelift to minor touch up procedures such as temporal lifts, eyelid tucks, neck lifts, or chemical peels. There is no absolute limit to the number of rejuvenation operations that can be done, but it is unusual for a patient to have more than 3 procedures in a lifetime.
Is the operation painful?
The surgery is usually done under local anesthesia with intravenous (IV) sedation. There is mild discomfort associated with injection of the local anesthetic, however you will be sedated during that time. There should be minimal or no pain associated with the operation itself. We have never had a patient we have not been able to comfortably complete.
How long does the operation take?
A facelift usually takes 2-3 hours. If other procedures are being done at the same time, additional time will be required. For instance, an upper and/or lower eyelid tuck will add about 1 1½ hours and a brow (forehead) lift may add 1 – 1½ hours.
Will there be any swelling or bruising?
There is always bruising and swelling. This will range from very little to quite a lot often depending on how diligent you are at staying elevated, quiet, and icing. Also, some people tend to bruise and swell more easily. Past experiences with injuries should clue you as to how you might respond. Normally, most of the swelling and bruising are gone within 2 weeks, but it can persist beyond this time.
When can I wear makeup?
Makeup can be applied to the skin 10 - 14 days after surgery. However, care should be taken not to rub or stretch the skin as it is applied especially in the area of the incisions. The doctor or his assistant will tell you when you can wear makeup as well as wash and dry your hair.
When can I return to normal activities?
You should physically be able to resume very light activity within 3-4 days and normal activity after 2-3 weeks. You will most likely appear "normal", without noticeable swelling or bruising, in 2 4 weeks. Exercise that results in an elevated blood pressure, an increased heart rate, or any sweating is not recommended for 3 weeks. You may take short, slow walks after the first 2 weeks, but other, more strenuous exercise is not recommended. Allow yourself plenty of rest and recuperation time for the best long-term results.
We are excited to help you through your facial plastic surgery. Please call if you have other questions or would like to schedule a consultation. (916) 564-8888
